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1984, 07-09 Permit App: 00001070 Residencey 3QL/ G~v BUILDING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND (Please return this original and your building plans to the Department of Building and Safety) 1 Owner's Name ,,,,, (last) , (first) (m) : ,>. s _ 11 .�-dt_ a. Department_Use�nly Res. v Comm 2 Project Ad�drr�; (not Mailing AcjF7ress) or Road Na Space Zip 3V sip0 .DSC. 3 City/Community spate l Subdivision/PlatNaamwe 4 A6seesor Parcel No. l 3�cq 1 _ eke.d- ✓-' Lot /1' Block 7 * * * DEPARTMEE/NyT�USE ONLY * * * 5 Sic Code Zone Act. # Zone �� �— Project No. ( " 6 Dwell k �� No. of Buildings Sq. Ft./Acre Depth / /- Frontage el°� 7 Set Back -Front (L)S-1 7 a- 1 (R)S-2 Reartc t 41. (bnsu9 Tract Module No. Is 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( ) tractor Firm Name �'{ ; ; l '+e,, v'1` C Street Address ,` S/ "7 his .f�;�,/� t� • t: < Zip i jPerson Clt�y`` tate PhonePhone ?,,,,e- tact License No. alb .r& t .. ` ". IFL—J - �°j c-- ic... i1 t� Phone If different than above ( ) Owner/Age t (if different than S1 abov)) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Ch� C/N) J Other (YINN)S `I/ SEPA Exempt (Y/N) Date 15 Type Work ii/ Bldg ❑ Fire El MH ❑ Demo X New ❑ Add/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work 10 Applicant Name Street Address 11 Zip City State Phone ( ) Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information I GOO ' KA r 6.24 41 E Application Type (Standard unless otherwise indicated) Fast Track Early Start DEPARTMENT APPROVALS This is nota Permit (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) Environmental Health W. 1101 College Room 200 ❑ Commercial; ❑ New Construction; ❑ Additional structure; ❑ Residential ❑ Bldg alteration/addition APPLICATION # Conditions/Comments• —� Ek.r+ Release Release w/cond 1 Hold 2 Ng - Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ❑ CU, variance, zone change; shoreline; ❑ fence; ❑ Other Conditions/Comments• Engineers: ❑ Commercial; ■ • sidential; N. 811 Jefferson ❑ drainage ❑ road improvements Conditions/Comments• new access/approach; ❑ Flood Plain; ❑ fence; ',yet Utilities: N. 811 Jefferson Conditions/Comments' Other: El Plan Exam Fire Prev. Conditions /Comments* Project Representative Agencies Performing Special Inspection: 1 Telephone 2 3 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold 2»//i Ln 1_b-1- 2 L k R A cic{n .